Evidence of Impact: iCCM as a strategy to save lives of children under five.

BACKGROUND: In 2013, the World Health Organization (WHO) launched the Rapid Access Expansion (RAcE) programme in the Democratic Republic of Congo, Malawi, Mozambique, Niger, and Nigeria to increase coverage of diagnostic, treatment, and referral services for malaria, pneumonia, and diarrhea among children ages 2-59 months. In 2017, a final evaluation of the six RAcE sites was conducted to determine whether the programme goal was reached. A key evaluation objective was to estimate the reduction in childhood mortality and the number of under-five lives saved over the project period in the RAcE project areas. METHODS: The Lives Saved Tool (LiST) was used to estimate reductions in all-cause child mortality due to changes in coverage of treatment for the integrated community case management (iCCM) illnesses - malaria, pneumonia, and diarrhea - while accounting for other changes in maternal and child health interventions in each RAcE project area. Data from RAcE baseline and endline household surveys, Demographic and Health Surveys, and routine health service data were used in each LiST model. The models yielded estimated change in under-five mortality rates, and estimated number of lives saved per year by malaria, pneumonia and diarrhea treatment. We adjusted the results to estimate the number of lives saved by community health worker (CHW)-provided treatment. RESULTS: The LiST model accounts for coverage changes in iCCM intervention coverage and other health trends in each project area to estimate mortality reduction and child lives saved. Under five mortality declined in all six RAcE sites, with an average decline of 10 percent. An estimated 6200 under-five lives were saved by malaria, pneumonia, and diarrhea treatment in the DRC, Malawi, Niger, and Nigeria, of which approximately 4940 (75 percent) were saved by treatment provided by CHWs. This total excludes Mozambique, where there were no estimated under-five lives saved likely due to widespread stockouts of key medications. In all other project areas, lives saved by CHW-provided treatment contributed substantially to the estimated decline in under-five mortality. CONCLUSIONS: Our results suggest that iCCM is a strategy that can save lives and measurably decrease child mortality in settings where access to health facility services is low and adequate resources for iCCM implementation are provided for CHW services.

iCCM data quality: an approach to assessing iCCM reporting systems and data quality in 5 African countries.

BACKGROUND: Ensuring the quality of health service data is critical for data-driven decision-making. Data quality assessments (DQAs) are used to determine if data are of sufficient quality to support their intended use. However, guidance on how to conduct DQAs specifically for community-based interventions, such as integrated community case management (iCCM) programs, is limited. As part of the World Health Organization's (WHO) Rapid Access Expansion (RAcE) Programme, ICF conducted DQAs in a unique effort to characterize the quality of community health worker-generated data and to use DQA findings to strengthen reporting systems and decision-making. METHODS: We present our experience implementing assessments using standardized DQA tools in the six RAcE project sites in the Democratic Republic of Congo, Malawi, Mozambique, Niger, and Nigeria. We describe the process used to create the RAcE DQA tools, adapt the tools to country contexts, and develop the iCCM DQA Toolkit, which enables countries to carry out regular and rapid DQAs. We provide examples of how we used results to generate recommendations. RESULTS: The DQA tools were customized for each RAcE project to assess the iCCM data reporting system, trace iCCM indicators through this system, and to ensure that DQAs were efficient and generated useful recommendations. This experience led to creation of an iCCM DQA Toolkit comprised of simplified versions of RAcE DQA tools and a guidance document. It includes system assessment questions that elicit actionable responses and a simplified data tracing tool focused on one treatment indicator for each iCCM focus illness: diarrhea, malaria, and pneumonia. The toolkit is intended for use at the national or sub-national level for periodic data quality checks. CONCLUSIONS: The iCCM DQA Toolkit was designed to be easily tailored to different data reporting system structures because iCCM data reporting tools and data flow vary substantially. The toolkit enables countries to identify points in the reporting system where data quality is compromised and areas of the reporting system that require strengthening, so that countries can make informed adjustments that improve data quality, strengthen reporting systems, and inform decision-making.

Immunosuppressive agents in adult kidney transplantation in the National Health Service: a model-based economic evaluation.

BACKGROUND: Immunosuppression is required in kidney transplantation to prevent rejection and prolong graft survival. We conducted an economic evaluation to support England's National Institute for Health and Care Excellence in developing updated guidance on the use of immunosuppression, incorporating new immunosuppressive agents, and addressing changes in pricing and the evidence base. METHODS: A discrete-time state transition model was developed to simulate adult kidney transplant patients over their lifetime. A total of 16 different regimens were modelled to assess the cost-effectiveness of basiliximab and rabbit anti-thymocyte globulin (rabbit ATG) as induction agents (with no antibody induction as a comparator) and immediate-release tacrolimus, prolonged-release tacrolimus, mycophenolate mofetil, mycophenolate sodium, sirolimus, everolimus and belatacept as maintenance agents (with ciclosporin and azathioprine as comparators). Graft survival was extrapolated from acute rejection rates, graft function and post-transplant diabetes rates, all estimated at 12 months post-transplantation. National Health Service (NHS) and personal social services costs were included. Cost-effectiveness thresholds of £20 000 and £30 000 per quality-adjusted life year were used. RESULTS: Basiliximab was predicted to be more effective and less costly than rabbit ATG and induction without antibodies. Immediate-release tacrolimus and mycophenolate mofetil were cost-effective as maintenance therapies. Other therapies were either more expensive and less effective or would only be cost-effective if a threshold in excess of £100 000 per quality-adjusted life year were used. CONCLUSIONS: A regimen comprising induction with basiliximab, followed by maintenance therapy with immediate-release tacrolimus and mycophenolate mofetil, is likely to be effective for uncomplicated adult kidney transplant patients and a cost-effective use of NHS resources.

Systematic review of topical capsaicin in the treatment of pruritus.

OBJECTIVE: To determine the efficacy of topical capsaicin in treating pruritus in any medical condition. DATA SOURCES: Cochrane library, Medline, Embase, Cinahl and Amed, up to April 2008. No language restrictions. STUDY SELECTION: Randomized, controlled trials comparing topically applied capsaicin with placebo or other standard treatment in patients with pruritus, independently selected by two reviewers. DATA EXTRACTION: Independently extracted by two reviewers. Quality assessed using the Jadad scale. DATA SYNTHESIS: Six randomized controlled trials were identified for inclusion. Three were for hemodialysis-related pruritus and provided insufficient data for the efficacy of topical capsaicin to be evaluated. A crossover study of capsaicin for treating idiopathic intractable pruritus ani reported a statistically significant difference in responder rates favoring capsaicin over placebo for itching scores but included insufficient data for the validity of this result to be assessed. A study on notalgia paresthetica reported a statistically significant difference in the first phase of a crossover study favoring capsaicin over placebo in a visual analogue scale for itch intensity but failed to report data for a second outcome measure. The final study on brachioradial pruritus used an inappropriate design and reported no significant reduction in itch between capsaicin and placebo. CONCLUSION: At present, there is no convincing evidence for the use of capsaicin to treat pruritus in any medical condition. Further research is needed, and should attempt to address methodological issues identified through this review including unblinding and the suitability of crossover designs.

Mindfulness-based cognitive therapy: evaluating current evidence and informing future research.

Mindfulness-based cognitive therapy (MBCT) is a recently developed class-based program designed to prevent relapse or recurrence of major depression (Z. V. Segal, J. M. G. Williams, & J. Teasdale, 2002). Although research in this area is in its infancy, MBCT is generally discussed as a promising therapy in terms of clinical effectiveness. The aim of this review was to outline the evidence that contributes to this current viewpoint and to evaluate the strengths and weaknesses of this evidence to inform future research. By systematically searching 6 electronic databases and the reference lists of retrieved articles, the authors identified 4 relevant studies: 2 randomized clinical trials, 1 study based on a subset of 1 of these trials, and 1 nonrandomized trial. The authors evaluated these trials and discussed methodological issues in the context of future research. The current evidence from the randomized trials suggests that, for patients with 3 or more previous depressive episodes, MBCT has an additive benefit to usual care. However, because of the nature of the control groups, these findings cannot be attributed to MBCT-specific effects. Further research is necessary to clarify whether MBCT does have any specific effects.

An investigation of the contents of complementary and alternative medicine journals.

CONTEXT: Previous research suggests that complementary and alternative medicine (CAM) journals publish few clinical trials, systematic reviews, and meta-analyses and a high proportion of positive articles. OBJECTIVE: This study describes the content of major CAM journals in 2005 and compares key findings with secondary data from previous years. DESIGN: PubMed-indexed CAM journals publishing in 2005 were identified using the search term "(alternative OR complementary) AND medicine." Review journals were excluded. All 2005 issues of the included journals were obtained and articles read. Articles were coded according to predefined criteria regarding the type of publication, area of CAM, and whether the outcome was positive, negative, or open. For comparison purposes, secondary data from 1995 and 2000 were obtained from previous research. RESULTS: Six journals publishing in 2005 (363 articles) were coded. Two datasets were produced, one excluding and one including recently established journals (2005a and 2005b, respectively). Proportionally fewer articles were clinical trials in 2005 (2005a=22.1%; 2005b=18.5%) than in 2000 (22.7%) and 1995 (27.7%). More than 50% of the 2005 articles were positive (2005a=51.1%; 2005b=50.7%), compared with 55.9% in 1995 and 43.5% in 2000. CONCLUSIONS: There is an apparent shift away from effectiveness research in CAM journals. This requires further investigation, and comparisons with other journals are needed. The large proportion of positive articles published in CAM journals appears to not adequately reflect the best available effectiveness evidence. This has implications for those using CAM journals as their main source of information in this area.